Healthcare Provider Details

I. General information

NPI: 1720377856
Provider Name (Legal Business Name): MICHAEL LEONCE PEZOLD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1162 MONTGOMERY DR STE 300
SANTA ROSA CA
95405-4802
US

IV. Provider business mailing address

1162 MONTGOMERY DR STE 300
SANTA ROSA CA
95405-4802
US

V. Phone/Fax

Practice location:
  • Phone: 707-890-4250
  • Fax: 707-476-2240
Mailing address:
  • Phone: 707-890-4250
  • Fax: 707-476-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number276415
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA168740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: